摘要
目的探讨思维导图在妇科运行病历书写及质量控制中的应用及效果。方法从体温单、医嘱单、护理记录单和特殊事件记录单4个方面切入,自行设计条理清晰的思维导图,成立思维导图应用培训考核小组,采用理论培训和情景模拟实践应用,进行考核和评价,并比较思维导图应用前后护理病历书写不完整问题的发生例次。结果核查168份病历,思维导图应用后查出护理病历书写不完整的问题85例次,较应用前的397例次有较大的改善,改善幅度为78.6%。结论思维导图层次分明、条理清晰,提高了护士的病历书写能力,从而提高了病历书写质量。
Objective To evaluate the effects of mind map in the writing and quality control of nursing records in the Gynecology Department.Methods Mind maps for the temperature sheet,physician＇s order sheet,nursing records and special event records were designed.A mind map training team was set up to train nurses by using theoretical training and scenario simulation.The frequency of writing problems in nursing records was compared before and after the application of mind map.Results After the application of mind map,85 issues among 168 nursing records were detected and the frequency of problems decreased by 78.6％.Conclusions The implement of mind map can improve nurses＇ ability of writing nursing records and enhance the quality of nursing records.
出处
《中华护理杂志》
CSCD
北大核心
2014年第7期836-839,共4页
Chinese Journal of Nursing
